Physician CDI Preparation for ICD-10
Timothy N. Brundage, MD, CCDS
Certified Clinical Documentation Specialist

“We do not believe there is anything inappropriate,
unethical, or otherwise wrong with hospitals taking full
advantage of coding opportunities to maximize
Medicare payment that is supported by
documentation in the medical record.”
◦ CMS 2008 IPPS Final Rule,
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS1533-FC.pdf, page 208
Clinical
Medicine
Medical
Record
Utilization
Quality
Medical legal
Data
Coded
Reimbursement
Physician
Profiles
&
Hospital
Report
Cards
Physician documentation in the medical record is an important
instrument in the economics of healthcare
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Cost per patient
Resource utilization
Length of stay
Complication Rates
Morbidity Scores
Mortality Scores
Outcome Analysis
Audits
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Documentation reflects severity of illness (SOI) and risk of
mortality (ROM) scores.
Specificity is vital, a definitive diagnosis must be
documented.
Physician profiles are developed from documented
information
Golden Rule: “If it is not written in coding language, it didn’t happen”
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ICD-9
◦ 1977 – Worldwide use
◦ 1979 – U.S. modification
 Clinical & mortality

ICD-10
◦ 1994 – Release of full ICD-10 by WHO
 Published in 42 languages
◦ 1999 – Adopted for death certificates in the United States
 Mortality
◦ 2014 – U.S. modification
 Clinical

ICD-11
◦ 2015 – Tentative rollout worldwide
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ICD-9-CM diagnosis

◦ 3–5 characters
◦ Allows for 1 letter (1st
position); otherwise numeric

◦ 3 to 7 characters
◦ 1st character is alpha (except
U); others are either alpha or
numeric
 Numbers 0–9; letters A–H,
J–N, P–Z
 Alpha characters are not
case-sensitive
ICD-9-CM procedures
◦ 4 characters only
◦ All characters are numeric
ICD-10-CM

ICD-10-PCS
◦ Same as ICD-10-CM except
each code must have 7
characters
 Letter “Z” used as a placeholder
7
Numeric or alpha
(E or V)
4
V
X
E
5
Numeric
1
X
4
X
.
Category
0
X
0
X
Etiology, anatomic
site, manifestation
3–5 characters
8
Alpha
(except U)
S X
3 X
2
M
X
A
Category
2–7 numeric or alpha
.
Additional
characters
0 X
1 X
0
X
A
X
Etiology, anatomic
site, severity
Added code extensions (7th
character) for obstetrics,
injuries, and external causes
of injury
3–7 characters
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The most challenging aspect of CDI
How do you motivate physicians
to educate themselves?
• Without all diagnoses documented, profiles will inappropriately
reflect higher than expected mortality
• Complete documentation, reflective of the true severity of illness
of patients will justify outcomes
Profiles are used for both commercial and public use
Future reimbursement methods will likely incorporate profiles in the
formula (e.g., pay for performance)
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Hospital Report cards
Healthgrades, Delta Group, Leapfrog
Medicare Physician Data (since 2007)
Federal and state regulatory agencies (e.g. OIG)
The Joint Commission (TJC)
Centers for Medicare and Medicaid Services (CMS)
Quality Improvement Organizations (QIO)
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Predicted Mortality Rates for some disease processes in
this case:
◦ Community Acquired Pneumonia = 10%
◦ Sepsis = 30%
◦ Septic shock = 50%
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If the patient survives, quality ratings will be much higher
in the public reporting data because the physician took
care of a “sicker” patient.
☻Expected mortality will be higher than actual mortality.
Don’t need to turn doctors into coders
 Need good documentation habits
 Need specialty specific documentation
education
 Begin the process of education now for ICD-9
and incorporate ICD-10 issues into the
education
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